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World Health Organization Updated Guidelines on the Prevention & Management of Acute Malnutrition

In July 2023, the World Health Organization (WHO) released updated guidelines for the management section of wasting and nutritional oedema, also known as acute malnutrition, in infants and children under 5. An update of the prevention section of the guidelines is expected this fall. The guidelines build on the 2013 guidelines by further enhancing care of infants and children with wasting and nutrition oedema as these conditions lead to higher mortality rates and other negative health outcomes. The guidelines were drafted and completed as one of the key commitments of WHO to the Global Action Plan for Child Wasting which was released in 2019 by the United Nations (UN) Secretary-General. The guidelines include four areas of focus:

  • Management of infants less than 6 months of age at risk of poor growth and development,
  • Management of infants and children 6-59 months with wasting and/or nutritional oedema,
  • Post-exit interventions after recovery from wasting and/or nutritional oedema, and
  • Prevention of wasting and nutritional oedema from a child health perspective (to be developed).

Ongoing crises such as climate change, the COVID-19 pandemic, conflict, and rising costs of food have exacerbated rates of malnutrition, particularly among those under 5 years of age. Currently, over 45.4 million infants and children under 5 years of age experience wasting each year. Governments and other stakeholders have struggled to make progress on Sustainable Development Goal 2 which is to reach “Zero Hunger” by 2030. The new guidelines include 19 total recommendations, 12 of which are new and 7 of which are updated, along with 10 good practice statements. Key recommendations and good practice statements for each focus area include:

Focus area: Management of infants less than 6 months of age at risk of poor growth and development

  • Admission, referral, transfer and exit criteria for infants at risk of poor growth and development:
    • Referring infants for inpatient care if they have one or more Integrated Management of Childhood Illness (IMCI) danger signs, acute medical problems, or conditions under severe classification as per IMCI, nutritional oedema, or recent weight loss. If they do not meet any of the above criteria, an in-depth assessment should be conducted to determine if inpatient admission or outpatient management is necessary and guidelines are provided on transitioning from inpatient care to outpatient care as well as to transferring out of, and/or ending outpatient care due to improved health status and growth and development.
    • Follow-up visits, with possible reduced frequency of visits, should continue until 6 months of age followed by referral to appropriate services.
  • Management of breastfeeding/lactation difficulties in mothers/caregivers of infants at risk of poor growth and development
    • Comprehensive assessments should be conducted by health care providers and best practices for managing breastfeeding/lactation challenges should be followed.
  • Supplemental milk for infants at risk of poor growth and development
    • For infants less than six months of age with severe wasting and/or nutritional oedema who are admitted for inpatient care should be breastfed where possible and support should be provided to the mothers or female caregivers. If an infant is not breastfed, support should be given to the mother or female caregiver to re-lactate. If this is not possible, wet nursing should be encouraged. A supplementary feed should be provided when clinically necessary. An assessment of the physical and mental health status of mothers or caregivers should be promoted and relevant treatment or support provided.
  • Interventions for mothers/caregivers of infants at risk of poor growth and development
    • To optimize growth and development in infants at risk of poor growth and development, a comprehensive assessment and support is recommended to ensure maternal/caregiver physical and mental health and wellbeing.

Focus area: Management of infants and children 6-59 months of age with wasting and/or nutrition oedema

  • Admission, referral, transfer, and exit criteria for infants and children with severe wasting and/or nutritional oedema
    • Referring infants and children (6-59 months) with severe wasting and/or nutritional oedema for inpatient care if they have one or more Integrated Management of Childhood Illness (IMCI) danger signs, acute medical problems, severe nutritional oedema, or poor appetite (failed appetite test). If they do not meet any of the above criteria, an in-depth assessment should be conducted to determine if inpatient admission or outpatient management is necessary and guidelines are provided on transitioning from inpatient care to outpatient care as well as to transferring out of, and/or ending outpatient care due to improved health status and growth and development. Continuity of care is vital for the safe and effective follow-up of infants and children with severe wasting and/or nutritional oedema. Ongoing medical and psychological support services are key and one important aspect of discharge panning is assessing the child’s home environment to ensure environmental health aspects (water, sanitation, hygiene), food security, economic stability, and the mental and physical health of caregivers.
  • Identification of dehydration in infants and children with wasting and/or nutritional oedema
    • Classifying hydration status in children with wasting and/or nutritional oedema to provide and monitor appropriate treatment.
  • Rehydration fluids for infants and children with wasting and/or nutritional oedema and dehydration but who are not shocked
    • Providing appropriate rehydration fluids, like Rehydration Solution for Malnourished Children (ReSoMal) or Oral Rehydration Solution (ORS).
  • Hydrolyzed formulas for infants and children with severe wasting and/or nutritional oedema who are not tolerating F-75 or F-100
    • There is insufficient evidence to recommend switching to hydrolyzed formulas if they are not tolerating F-75 or F-100 milks.
  • Ready-to-use therapeutic foods (RUTF) for treatment of severe wasting and/or nutritional oedema
    • RUTF should be given in specific quantities that will provide 150-185 kcal/kg/day until anthropometric recovery and resolution of nutritional oedema; or 150-185 kcal/kg/day until the child is no longer severely wasted and does not have nutritional oedema, then the quantity can be reduced to provide 100-130 kcal/kg/day, until anthropometric recovery and resolution of nutritional oedema.
  • Dietary management of infants and children with moderate wasting
    • Nutrient dense diet should be provided to meet extra needs or recovery of weight and height and for improved survival, health, and development.
    • Those with moderate wasting should be assessed comprehensively and treated wherever possible for medical and psychosocial problems leading to or exacerbating this episode of wasting.
    • Specially formulated foods (SFF) interventions with counseling should be considered with a number of clinical factors, including failing to recover from moderate wasting, co-morbidities, and others, in addition to social factors like poor maternal health and wellbeing.
    • SFF as well as counseling and the provision of home foods for them and their families should be considered.
    • For those needing supplementation with SFF, lipid-based nutrient supplements (LNS) are the preferred type. When not available, Fortified Blended Foods with added sugar, oil, and/or milk are preferred compared to Fortified Blended Foods without these attributes. Additionally, SFF should be given to provide 40-60% of the total daily energy requirements needed to achieve anthropometric recovery. High-risk moderate acute malnutrition is defined with a mid-upper arm circumference (MUAC) of 11.5 to <11.9 or weight-for-age (WAZ) <-3.5.
  • Identification and management of wasting and nutritional oedema by community health workers
    • Assessment, classification and management or referral of infants and children 6-59 months of age with wasting and/or nutritional oedema can be carried out by community health workers as long as they receive adequate training, and regular supervision of their work is built into service delivery.

Focus area: Post-exit interventions after recovery from wasting and/or nutritional oedema

  • Support for mothers/caregivers should be provided after infants and children are treated for wasting and/or nutritional oedema. This can include counseling and education, responsive care, and safe water, hygiene, and sanitation interventions.
  • Psychosocial stimulation should continue to be provided by mothers/caregivers after transfer from inpatient to outpatient treatment.
  • Cash transfers in addition to routine care may be provided to decrease relapse and improve overall child health during outpatient care and after exit from treatment, depending on contextual factors such as cost.
  • In infants and children with severe wasting and/or nutritional oedema who are HIV negative, daily oral co-trimoxazole prophylaxis should not be provided after transfer from inpatient treatment and/or exit from outpatient treatment as part of routine care.

Additional standing WHO recommendations and best practice statements on wasting and nutritional oedema were also carried over from previous guidelines, including classifying nutritional status according to WHO child growth standards, providing children with severe wasting and/or nutritional oedema the recommended daily nutrient intake of vitamin A throughout treatment period, promotion and support for exclusive breastfeeding in the first 6 months and continued breastfeeding until 24 months and beyond, and others.

In addition to these guidelines, WHO will be putting out operational guidance to accompany them. As policymakers, governments and governmental agencies, program implementers, non-governmental organizations and other civil society organizations, and healthcare workers aim to reduce and prevent wasting and nutrition oedema in infants and children, they should rely on these guidelines to develop and implement evidence-based policies, programs, best practices, and regulations.

Transforming How We Advocate for Women’s Nutrition

1,000 Days was born in 2010 out of ground-breaking scientific evidence that found there was a brief but powerful window of opportunity from a woman’s pregnancy to a child’s 2nd birthday to enhance the development and long-term health of individuals and societies. The research showed that investing in proven, cost-effective nutrition interventions in that first 1,000 days can lead to lower child and maternal mortality and healthier moms and babies.

Our organization set out to raise awareness of these findings and focus on improving policies and increasing much-needed resources for nutrition in the 1,000-day window. Research continues to prove that early investments in nutrition provide the foundation for children to develop to their full potential, setting them up for later success in school and the workforce, and reducing a child’s predisposition to obesity and other illnesses later in life.

But here’s something we’ve noticed over the years: at times, the nutrition community has so ardently celebrated the amazing potential impact of investments in the first 1,000 days that discussions of a woman’s nutrition have tended to narrowly focus on the impact her nutrition has on her newborn child. A woman plays an incredibly important and indisputable role in the health and development of her child – but all too often, a woman’s own right to long-term health and nutrition is overlooked.

Nutrition as a step toward gender equality

Women and girls often struggle to access adequate nutrition due to their status in a society.  In fact, they represent 60% of all undernourished people in the world and a recent analysis by UN Women found that two thirds of countries report higher rates of food insecurity for women compared to men. On top of that, women and adolescent girls have special nutritional needs tied to their reproductive health and menstruation. Today, it is estimated that more than one billion women and girls do not have access to the adequate nutrition and healthy diets they need to survive and thrive.

This inequity has deep consequences because investing in a woman’s nutrition not only helps her deliver a healthy baby, it is a basic right for women everywhere to lead healthy and productive lives and in turn, these investments support gender equality. We know that the right nutrition is part of the fight for gender equality because of the impact it has in three key areas—her health, her education and her ability to earn an income:

  • Her health: Proper nutrition during the 1,000-day window can have a significant impact on the health and well-being of a woman. This is especially pertinent during and after pregnancy, a critical period in women’s lives, especially since maternal mortality is still a leading cause of death in low resource settings. Additionally, breastfeeding, which nutrition programming helps promote, protect, and support, is associated with lower risk of heart disease – the leading cause of death among women in the U.S. – as well as breast cancer, ovarian cancer and Type-2 diabetes later in life. There are also benefits beyond the 1000-day window. Women who are well nourished are less susceptible to infectious diseases such as HIV/AIDS, malaria and tuberculosis, and have a lower prevalence of diet-related non-communicable diseases such as diabetes and cardiovascular disease.
  • Her education: An education is key for girls seeking a better future, and one of the most critical investments in a gender equal world. Each year of schooling increases a woman’s earnings by as much as 10-20%, moving many women towards achieving financial independence and closing the gender-based earning gap. While gender disparities in school enrollment have multiple causes, malnutrition and food insecurity can also play a role. In low income countries, the promise of at least one meal provided at school can motivate parents to choose to prioritize education over staying home to work or care for other family members. Further, well-nourished girls are more likely to perform better in school and reach higher levels of education. In India, for example, girls who received school meals showed a 30% higher chance of completing primary school.
  • Her earning potential: And finally, improving nutrition helps increase women’s earning potential. It is well-known that children who are well-nourished in the 1000-day window are more likely to learn better in school and have higher paying jobs – earning 25% more than those without proper nutrients early in life. Proper nutrition can also have an outsized effect on adult women. Eliminating anemia alone could increase adult productivity by up to 17%, helping break the cycle of poverty and malnutrition for the next generation.

We must do more

Many of these returns from nutrition investments on health, education, and earning potential are not unique to women. Good nutrition is fundamental to every person’s ability to live a healthy, productive life. But it is time we acknowledge that gender equality itself is further advanced when women and girls get the nutrition they need, and that a woman’s all-too-often diminished role in society negatively impacts her ability to be well-nourished. We need programs and policies that support all the ways that nutrition helps women achieve what they want – whether it’s a healthy body, high marks in school, or a high-powered career. The focus on women’s nutritional needs has been predominantly oriented towards ensuring that she can provide the best health outcomes for her child, but ensuring women have access to proper nutrition can do even more – it can help her grow her power. We need to start focusing more attention on ensuring that women have access to the right nutrition at every stage of a woman’s life if we want to make a meaningful impact on gender equality.

Breastfeeding bills to look for in the 118th Congress

Breastfeeding bills to look for in the 118th Congress

Success in breastfeeding is everyone’s responsibility. In anticipation of the 118th Congress (2023), we’ve pulled together a short list highlighting the breastfeeding-related bills we support, because we know increased breastfeeding support is multifaceted and multisectoral. It envelops a wide range of environments from birthing spaces to places of work and even the halls of Congress. We believe these bills will improve policies and increase investments to enable more people to reach their breastfeeding goals.

Federal Nutrition Programs
The Wise Investment in Children (WIC) Act
This bill would extend eligibility for postpartum women to receive benefits under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to two years postpartum, extend the program certification window to two years to reduce attrition, and allow children to receive WIC benefits through their sixth birthday.

Access to Donor Milk
The Access to Donor Milk Act (ADMA)
This bill would help increase life-saving access to donor milk, particularly important in light of the 2022 formula recall and shortage, and as part of a robust infrastructure for infant nutrition security.

 Access to Quality, Comprehensive Health Care
Improving Coverage and Care for Mothers Act
This bill would expand eligibility for Medicaid to all who are pregnant or within one year postpartum. It would also authorize Medicaid to extend coverage of services provided to include lactation consultants. As the bill highlights, a lactation consultant is a health professional trained to focus on the needs and concerns of a breastfeeding mother and baby, and to prevent, recognize and solve breastfeeding difficulties.

The Mothers and Offspring Mortality and Morbidity Awareness (MOMMA’s) Act
This bill would expand eligibility for Medicaid up to one year postpartum, and for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) up to two years postpartum.

Health Equity
The Black Maternal Health Momnibus Act
This bill would comprehensively address every dimension of the Black maternal health crisis in America by making critical investments in social determinants that influence health outcomes and confront issues of systemic racism in the medical system. It would also establish grant programs to increase the number of perinatal health workers – including lactation consultants and dietitians – who offer culturally congruent support.

Paid Family and Medical Leave
The Family and Medical Insurance Leave (FAMILY) Act
This bill would provide comprehensive paid family and medical leave of up to 12 weeks to all workers in the United States. Categorically recognizing paid leave as a public health imperative, this bill has the potential to transform the lives of families. As research shows, paid leave supports breastfeeding initiation and duration in a number of ways. For example, a person is more than twice as likely to stop breastfeeding in the month the person returns to work compared to someone who has not yet returned to work.

WIC Food Package Updates – Making a Critical Program Even More Impactful

WIC Food Package Updates – Making a Critical Program Even More Impactful

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a critical program in providing healthy foods and nutrition services for more than 6.3 million pregnant and postpartum women, infants, and children across the country.

Building on the program’s success and strengths, the U.S. Department of Agriculture (USDA) published a proposed rule to update the food packages to further reduce health disparities and ensure that all women and children have a healthy first 1,000 days. The proposed rule would permanently increase the Cash Value Benefit for fruits and vegetables, add seafood across food packages, increase whole grain options to better represent culturally-diversified recipes, include new substitution patterns and flexibility to improve participant access to WIC foods and support breastfeeding.

Why we’re excited

First, the proposed rules are more closely aligned with the latest research and science, such as this series in the American Journal of Public Health, so everyone is given the best, most up-to-date nutrition guidance.

In particular, we applaud USDA for increasing benefits for fruits and vegetables while decreasing juice in the proposed rule. This change better aligns with the recommendations in the Dietary Guidelines for Americans (DGA) to consume whole fruits and vegetables and limit juice intake in young children.  (Click here to learn more about serving juice to kids.)

We also commend the proposals to strengthen support for moms and babies across a wider range of breastfeeding options, including those that mostly, but not exclusively, breastfeed. These changes provide partially-breastfeeding people with food packages that align with their higher calorie needs and also adds flexibility to the amount of formula provided for partially-breastfed infants. These changes better support individual breastfeeding goals.

These additional flexibilities in the WIC food packages, along with the WIC breastfeeding peer counselor program, which connects moms with others from their community to provide education, encouragement and support, will help all moms with their infant feeding needs. It takes everyone to support breastfeeding, not just the mother. (To dive a little deeper, listen to this interview by former WIC breastfeeding peer counselor, Chrisonne Henderson.)

1,000 Days joins many of our partners in strongly supporting the proposed WIC food package changes. Nutrition in particular plays a foundational role in a child’s development. The proposed WIC food packages take a critical step in ensuring implementation of the Dietary Guidelines for Americans for families who need the extra support with healthy foods and nutrition education, which is critical to the health and well-being of parents and babies. (Check out these short videos about some of the DGA recommendations.)

What you can do

We invite you to join us in submitting supportive comments to USDA. The National WIC Association has a template and online submission form to make it quick and easy! Comments are due by February 21, 2023.

Keeping Healthy During Pregnancy & Breastfeeding

During pregnancy and when you’re breastfeeding, nutritious food choices will help fuel your
baby’s growth and keep you healthy.

Watch and learn 6 steps you can take during your 1,000-day window to nourish you and your little
one.

Taking a Prenatal Vitamin

Eating the Rainbow

Limiting Certain Foods

Managing your Weight

Focusing on Good Nutrition

Breastfeeding for the Benefits to You and Baby

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The Impact of MMS on Moms and Babies

Official title: Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries

Published: November 2017

Publication: The Lancet Global Health

Authors: Emily R Smith, Anuraj H Shankar, Lee S-F Wu, Said Aboud, Seth Adu-Afarwuah, Hasmot Ali, Rina Agustina, Shams Arifeen, Per Ashorn, Zulfiqar A Bhutta, Parul Christian, Delanjathan Devakumar, Kathryn G Dewey, Henrik Friis, Exnevia Gomo, Piyush Gupta, Pernille Kæstel, Patrick Kolsteren, Hermann Lanou, Kenneth Maleta, Aissa Mamadoultaibou, Gernard Msamanga, David Osrin, Lars-Åke Persson, Usha Ramakrishnan, Juan A Rivera, Arjumand Rizvi, H P S Sachdev, Willy Urassa, Keith P West Jr, Noel Zagre, Lingxia Ze

Read the original paper here.

Summary 

  • Pregnant women need extra nutrition for themselves and their babies.
  • Many pregnant women don’t get enough nutrients from the food they eat.  
  • Micronutrient deficiencies during pregnancy put both mothers and babies at risk of birth complications and death.
  • Lack of nutrients in this critical period can prevent children from reaching their full physical and mental potential.
  • To help avoid this, nutrition programs often give pregnant women iron and folic acid (IFA) to supplement the nutrients they get from the food they eat.
  • Recent research has suggested that women might be better off if they got a multiple micronutrient supplement (MMS) instead of just iron and folic acid (IFA). 
  • Researchers have been trying to figure out if MMS is safe, effective, and cheap enough to recommend switching out IFA and replacing it with MMS
  • This paper analyzed 17 different studies testing MMS and IFA.
  • The analysis found that compared to IFA, MMS:
    1. Reduced the risk of low birthweight babies, preterm babies, and small babies.
    2. Reduced the number of infant deaths in the days after birth, especially for girls. 
    3. Reduced the number of kids who were born to anemic mothers and died before 6 months.
    4. Reduced the number of preterm births.
  • Researchers also discovered something they hadn’t known before: The benefits of taking MMS during pregnancy instead of IFA were even bigger if moms were malnourished. Malnourished women who took MMS while they were pregnant saw an even greater decrease in low bithweight, preterm, and small births compared to malnourished women who only took IFA while they were pregnant. 
  • The studies didn’t find any negative effects of taking MMS

 

Conclusions

  • MMS is safe and more effective than IFA at preventing multiple conditions and death in newborns and babies, especially when moms are malnourished. 
  • The WHO should consider updating its guidelines to reflect the benefits of MMS

5 Actions Governments Can Take to Help Children Suffering from Wasting

Every 11 seconds, a child dies from malnutrition. Over the course of a year, that means that more kids die from malnutrition than the population of Chicago. The COVID-19 pandemic is making these numbers worse. Wasting is the most deadly form of malnutrition, and experts estimate that pandemic-related disruptions are going to create 13.6 million additional cases of wasting by the end of 2022.

It doesn’t have to be this way. Governments can scale key nutrition interventions to stop this crisis from escalating further.

Not only is there already a suite of proven, cost-effective nutrition interventions ready to be scaled today, but researchers have also identified several promising new innovations to treat child wasting that help every dollar go further and save more children.

Kids who are already wasted need access to high-quality, reliable treatment in the form of ready-to-use therapeutic foods (RUTF). Today, less than 25% of even the most life-threatening cases get any form of treatment, leaving the majority of wasted children with little hope of a full recovery. We need to do better to deliver this treatment to more kids, especially in hard-to-reach communities where last-mile service delivery is particularly critical.

However, there is also a lot we can do to make sure vulnerable kids don’t become wasted in the first place. To start, we can give children regular doses of vitamin A, support breastfeeding mothers, and make sure all pregnant women have the prenatal vitamins they need to have healthy pregnancies. We know that implementing these proven nutrition interventions at scale will reduce malnutrition rates. These interventions also come with an incredibly high return on investment, with leading economists consistently ranking nutrition interventions as some of the most cost-effective ways to save and improve lives around the world.

Governments have a critical role to play in addressing the wasting crisis. Governments are the backbone of the nutrition sector, ensuring solutions to global malnutrition are available, sustainable, widespread and locally appropriate. At the December 7-8  Nutrition for Growth summit, governments have the opportunity to make SMART commitments to address wasting and avert the worst effects of the pandemic. One of the most immediate things governments can do to reduce wasting rates is come to the stage at the Nutrition for Growth summit with measurable, ambitious financial pledges to scale the nutrition interventions that we know work. But funding alone will not solve this problem. We need to take steps to make limited resources go further. Here are five actions they can take:

  1. Work with UNICEF and other UN agencies to fund and implement the country-specific roadmaps for the Global Action Plan (or GAP) on child wasting.
    National governments have been key partners in developing robust Global Action Plan Country Roadmaps, and will be some of its primary implementers. In order to implement the GAP by 2030, governments around the world can set ambitious coverage targets for high-impact interventions and work with partners to execute their country’s roadmap and monitor their progress.
  2. Participate in WHO and UNICEF’s Guideline Review for child wasting prevention and treatment.
    WHO and UNICEF are currently reviewing and updating technical guidance on how to detect child wasting earlier and optimize the way it is treated. Once they have made  recommendations at the global level, they will focus on reviewing and revising national guidelines to reflect global updates. Governments can pledge to work with UNICEF and the WHO to revise their own national guidelines in line with the updated recommendations.
  3. Invest in innovative financing for wasting treatment
    Governments can engage with emerging opportunities to leverage innovative financing mechanisms to mobilize domestic resources. One recent example is the UNICEF-managed Nutrition Match Fund, which matches domestically mobilized spending on RUTF. Innovative financing can also help prevent supply chain disruptions by offering short term loans to cover temporary cash flow problems (for example, the nutrition window in the Vaccine Independence Initiative (VII)). Governments can also make sure they give implementers flexible funding for their wasting programming. This is important across development, humanitarian and fragile contexts. This flexible funding will help implementers in constantly evolving situations to stay adaptable and quickly direct resources where they need them most.
  4. Integrate wasting treatment services into existing health systems.
    One of the best ways to reach more kids with sustainable wasting treatment programs is to integrate treatment services into existing government-run health systems. Results 4 Development and UNICEF have recently released a detailed resource guide on how to do this. By pledging to develop and implement an integration plan, governments can ensure these programs outlast the life cycle of a single grant or program.
  5. Support ongoing research and innovation.
    In the past few years we have seen incredible advances in how to treat wasted kids more effectively for less money, but these innovations are just the beginning. Ending preventable child deaths from wasting will require ongoing research toward projects like finding a cheaper way to produce RUTF. In many cases, this research will involve identifying and building solutions to context-specific determinants and drivers of child wasting.

Nutrition for Growth is a chance to stand on the world stage and commit to ending malnutrition and preventable child deaths. Action begets action, and so every pledge does more than just fulfill its specific commitments. Pledges inspire other actors to join the movement, and build the momentum necessary to reach our ambitious goals.

As author and journalist Roger Thurow said, “A [malnourished] child anywhere in our world becomes a [malnourished] child everywhere — we all share in the cost of lower education, reduced labor productivity, and escalating health care costs. And perhaps, the greatest costs remain immeasurable — a poem never written, a song never sung, a story never told, a technology never invented, a cure never discovered, a horizon never explored.”

We have the building blocks we need to prevent these absences. All we need now is the will to act.